Leaders at the VA Eastern Colorado Health Care System in Aurora Created an Environment That Undermined the Culture of Safety

Report Information

Issue Date
Report Number
23-02179-188
VISN
19
State
Colorado
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Clinical Care Services Operations
Staffing
Major Management Challenges
Leadership and Governance
Recommendations
7
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) conducted an inspection to assess allegations that senior leaders failed to practice high reliability organization (HRO) principles and created a culture of fear at the VA Eastern Colorado Health Care System (facility) in Aurora.

The OIG substantiated the allegations and found key senior leaders created an environment where a significant number of clinical and administrative leaders and frontline staff, from a multitude of service lines, felt psychologically unsafe, deeply disrespected, and dismissed, and feared that speaking up or offering a difference of opinion would result in reprisal. Further, the OIG substantiated that following the addition of two key senior leaders to the peer review committee (PRC) in 2023, the culture of the committee changed to an environment perceived by six members, as well as non-PRC service leaders and staff, to be psychologically unsafe and punitive. When learning of concerns, key senior leaders missed opportunities to understand concerns and make efforts to foster a psychologically safe environment.

The OIG substantiated that mid-level leadership had been eroded and three key senior leaders held a monopoly of control. The OIG found leadership instability at the service level, with many clinical service and section-level resignations and extended vacancies. Further, numerous former leaders left facility employment citing that a psychologically unsafe work environment was a major factor in their decision to leave. Despite these losses, key senior leaders did not seek or utilize employee exit survey data to identify and address employee retention challenges.

Turnover in VISN leadership positions and ineffective communication contributed to the VISN Director’s lack of awareness regarding the extent of the staffing and culture challenges at the facility. The OIG made two recommendations to the Under Secretary for Health, four recommendations to the VISN Director, and one recommendation to the Facility Director.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health conducts a review of the Veterans Integrated Service Network leaders’ awareness and oversight of the VA Eastern Colorado Health Care System’s operations including clinical staffing, hiring and retention of qualified candidates, and leaders’ adherence to high reliability organizational principles.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Under Secretary for Health utilizes the above review to standardize Veterans Integrated Service Network leaders’ roles and responsibilities across the system to ensure each Veterans Integrated Service Network practices structured and robust oversight activities in support of high-quality healthcare delivery at each healthcare facility.

No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director conducts a review to determine whether the actions of the Facility Director, Chief of Staff, deputy chief of staff for inpatient operations, and the associate chief of staff for education created and reinforced a culture of fear and failed to adhere to high reliability organizational principles, and takes action as needed.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director develops and implements an avenue for VA Eastern Colorado Health Care System’s employees to provide periodic feedback regarding the culture of safety and leaders’ practice of and adherence to high reliability principles.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures the VA Eastern Colorado Health Care System Director evaluates clinical service leader vacancies throughout the facility and takes actions to prioritize the recruitment and hiring of qualified clinical leaders.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures human resources officers provide separating and transferring employees access to the most current version of the VA exit and transfer surveys.

No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Eastern Colorado Health Care System Director and leaders actively seek and utilize employee exit survey data to identify challenges with employee retention, develop and implement actions to address challenges, and evaluate the effectiveness of actions.